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Home My WebLink AboutBLD-23-002559 01.Y`141: / M I//q /Z ?Office Use Only -,.-� �; ;Permit# +! /� Y O i1,1� H ;Amount i Ud ` MATTACn [SE•, ', ,,,,,, ,.b d ;Permit expires 180 days from c� issue date 61M-a 3—6602.55 5 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth, MA 02664 NOV 08 2022 (508) 398-2231 Ext. 1261 _ _ �{ BUILDING DEPARTMENT CONSTRUCTION ADDRESS: / O J —`i 1.Q ` & / By= ASSESSOR'S INFORMATION: r n _ / ,�/� Map: J Parcel: / OWNER: PR-Y� / °/ cC4 4M 3 ��/°1 'V/ -p� V ?6 ,'3 qK NAME PRESENT ADDRESS TEL. # �7 / 6 CONTRACTOR:/3 l J i /J'/ '��' l� )L,Y ' � /I `7 b,042 & 7 6 3 9 V NAME MAILING ADD SS TEL.# k._ Residential ❑Commercial Est.Cost of Construction$ 3 6 Home Improvement Contractor Lie.# I U ` /(1-3 Construction Supervisor Lic.# /71 2 _s Wor s Compensation Insurance: (check one) k/ am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration ��,. (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares q_,r/ Replacement windows:# / Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: / /3-1"'4411,1--W r/ I "/ Location of Facility I declare under penalties of perjury that the statements herein contained are t and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial orr ocation of my ense and for c io i LG.L. h.268 ction 1. Applicant's Signature: / t V Date: /1// / Owners Signature(or attachment) / 1�- Date: ///i / ,L l / Approved By: Date: ;/ CC��'' Building Official esi" EMAIL ADD Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 01 No The Commonwealth of Massachusetts '* 1 Department of Industrial Accidents 1 Congress Street, Suite 100 1 Boston, MA 02114-2017 0 „5v•`''y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 1j `/✓,742 y Address: 3 2 % .-/ V i 2- p,0 City/State/Zip: W 91 0)0 drone -: 0 f-' Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. New construction 2.D I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑ Demolition I am a homeowner doing all work myself. [No workers'comp. insurance required.]t — Building addition 10 4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will _— ensure that all contractors either have workers'compensation insurance or are sole 11._ Electrical repairs or additions proprietors with no employees. 12. _Plumbing repairs or additions 5.EI I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t. 14.KOther6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. Sc��t� j' 152,§I(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. }Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy 4 or Self-ins. Lic. m: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert. under the pain and enalties of perju that the information provided above is true and correct. I`. /� //// Sig �nature: ��:�/ Date: /l d--`� Phone 4: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License 4 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: